Neurology & Pain Management Coding Alert

Note that prolonged services are add-on codes, which must be reported in addition to other physician services, including E/M services at any level. Note also that +99357 must be reported only in addition to +99356.

Prolonged services codes are time-based and may only be appended to other E/M codes that include a reference time (without this time component, there is no way to define a service as "prolonged"), says Linda Laghab, CPC, coding department manager for Pediatric Management Group at Children's Hospital, Los Angeles. Specifically, section 15511.1 of the Medicare Carriers Manual (MCM) dictates that +99356 and +99357 must accompany a claim of 99221-99223 (Hospital inpatient services), 99231-99233 (Subsequent hospital care), 99251-99255 (Initial inpatient consultations), 99261-99263 (Follow-up inpatient consultations), 99301-99303 (Comprehensive nursing facility assessments) or 99311-99313 (Subsequent nursing facility care).

Medicare carriers will not reimburse for prolonged services unless they are accompanied by an approved "companion" code, says Cathy Klein, LPN, CPC, medical policy specialist with Health Care Excel Inc. in Indianapolis. Prolonged services cannot be billed with:

When you report the first hour of prolonged services, the reference time for the primary E/M service must be exceeded by a minimum of 30 minutes. For neurologists providing t-PA administration, prolonged services would likely accompany a claim of initial hospital care (99221-99223) or, possibly, initial inpatient consults (99251-99255).

For example, the neurologist provides a level-three admit (99223) for a 55-year-old male stroke victim. Although the patient does not require attention at the level of critical care, he requires significant care and attention (including t-PA administration) beyond the 70-minute reference time assigned to 99223. If this additional time reaches 30 minutes, the neurologist may report one unit of +99356 in addition to the hospital admission.

For an additional half-hour of prolonged services, the total time required beyond the reference time of the primary E/M code must equal at least 75 minutes. The physician must account for at least 15 minutes of every additional half-hour billed. In the above example, if the care provided lasted a total of 150 minutes, the neurologist would report 99223, +99356 and +99357 (150 minutes - 70 minutes reference time = 80 minutes of prolonged services). If the total session only lasted 140 minutes, however, the additional half-hour is not allowable (140 minutes - 70 minutes reference time = 70 minutes, or only 10 minutes not the required 15 minutes beyond the first hour).

If warranted, physicians may report multiple units of 99357. For instance, using the above example, a three-hour session would be reported 99223, +99356, +99357 x 2 (180 minutes - 70 minutes reference time = 110 minutes, or one hour + 30 minutes + 20 minutes.)

Time counted toward prolonged services must occur on the same date of service but does not need to be continuous, Laghab says. The physician may tend to a patient in the hospital for 30 minutes, leave to perform regular rounds, and return to the original patient for another 40 minutes of care. The time spent with the patient before and after the physician conducted rounds can contribute toward prolonged services.

To count effectively, however, all time must be documented. "Documentation of time spent is the essential key to billing for prolonged service codes. Without an actual minute value stated in the physician notes, this code is not valid no matter how much time was actually spent," Laghab explains.

The MCM, section 15511.1, instructs carriers to "Advise physicians that to support billing for prolonged services, the medical record must document the duration and content of the E/M code billed." Simply noting that an extra 42 minutes were spent with the patient is not adequate: You must justify the extra time. "It must be clearly evident in the medical record what was billed for using the E/M service as well as for the prolonged service," Klein says.

Medicare does not require that the physician document start and stop times, but as is often the case with documentation, more is better.

CPT includes two codes for prolonged services without direct patient contact: +99358 (Prolonged evaluation and management service before and/or after direct [face-to-face] patient care [e.g., review of extensive records and tests, communication with other professionals and/or the patient/family]; first hour) and +99359 (... each additional 30 minutes).

Medicare has not assigned a relative value to these codes, and instructs payers not to reimburse for these services, reasoning that "payment for these services is included in the payment for direct face-to-face services that physicians bill" (i.e., the services are considered "bundled" into any E/M services provided). Therefore, you cannot bill the patient even with an advance beneficiary notice (ABN). You may report these codes for the sake of accuracy, but do not expect reimbursement from Medicare payers.

Note: Some third-party payers may recognize non-face-to-face codes. Check with the payers for guidelines.